MEDICARE: PIMSIRI KANGVONKIT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	37119	TX

General Provider Information

NPI Number	:	1528646965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PIMSIRI KANGVONKIT

Provider Business Mailing Address
First Line	:	4900 GAGE AVE APT 383
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1629
Country	:	US
Telephone Number	:	646-993-6595
Fax Number	:

Provider Business Practice Location Address
First Line	:	3411 SYCAMORE SCHOOL RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2091
Country	:	US
Telephone Number	:	682-233-9326
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2021
Last Update Date	:	09/22/2023

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Directions to “ PIMSIRI KANGVONKIT ” Practice Location

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